Bringing Evidence-Based Medicine to the Bedside:
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1 Bringing Evidence-Based Medicine to the Bedside: The Cleveland Clinic Clinical Decision Support System (DSS) Wolf H. Stapelfeldt, M.D. Chairman, Department of General Anesthesiology Vice Chairman, Surgical Operations Cleveland Clinic.
2 Bringing Evidence-Based Medicine to the Bedside 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically
3 Bringing Evidence-Based Medicine to the Bedside 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record
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5 Bringing Evidence-Based Medicine to the Bedside 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record c. Latest (second/third generation) Record >> Compliance language ARKS
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7 Bringing Evidence-Based Medicine to the Bedside 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record c. Latest (second/third generation) Record >> Compliance language ARKS Advantages 1. Legible 2. Accurate 3. Compliant (Billing Compliance) 4. Queryable
8 Bringing Evidence-Based Medicine to the Bedside 1. Current Status of Perioperative Care Problem if there are Complications ARKS
9 Three Important Issues 1) Time to respond is limited 2) Correct diagnosis and intervention may matter 3) Process is prone to (not immune from) failure Fluids? Ephedrine? Epinephrine? Vasopressor?
10 Healthcare Reliability Terminology (Different from the mathematical) Unstable process: Failure in greater than 20% of opportunities 10-1 : 80 or 90 percent success. 1 or 2 failures out of 10 opportunities 10-2 : 5 failures or less out of 100 opportunities 10-3 : 5 failures or less out of 1000 opportunities 10-4 : 5 failures or less out of 10,000 opportunities Postoperative Mortality Awareness Under Anesthesia
11 Model 10-1 concepts Intent, Vigilance and Hard Work: 10-1 Performance (designing basic failure prevention) Common equipment, standard orders sheets Personal check lists Feedback of information on compliance Awareness and training Working harder next time Model 10-2 concepts Human Factors and Reliability Science: 10-2 Performance (designing sophisticated failure prevention, basic failure identification and mitigation) Decision aids and reminders built into the system Desired action the default (based on evidence) Redundancy Takes advantage of habits and patterns Standardization of process
12 Electronic Recordkeeping and Decision Support 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information (the right information at the right time to make the right decision)
13 Electronic Recordkeeping and Decision Support 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS Web-Based Supervising Physician OR ARKS Pertinent, Patient-Specific Information Secure (electronically, physical) Compliant with Standards (HL7, SNOMED nomenclature) Platform-Independent Scalable Universally Applicable
14 Electronic Recordkeeping and Decision Support 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR DSS Knowledge Base Allows adverse physiologic developments to be addressed before they become crises ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR
15 Department of General Anesthesiology Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Triple Low ) Prospective randomized study of the Triple Low alert in 2010 Ongoing initiative - everyone s input is welcome Clinical Decision Support System (DSS)
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27 Department of General Anesthesiology Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Risk of Awareness) Role of Time Multiple Parameters Clinical Decision Support System (DSS)
28 Department of General Anesthesiology Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Risk of Awareness) Role of Time Specific Rules Multiple Parameters Clinical Decision Support System (DSS)
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31 Department of General Anesthesiology Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Risk of Awareness) Role of Time Specific Rules Multiple Parameters Clinical Decision Support System (DSS)
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33 Propofol Propofol
34 Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Risk of Awareness) Role of Time Specific Rules Multiple Parameters Clinical Decision Support System (DSS)
35 Department of General Anesthesiology Version 1.0 rolled out in January, 2010 Staff was in-serviced >> DSS Button became active in ARKS Passive information (vital signs, incl. pulse pressure variability; reference texts, with links from patient diagnoses; CC Formulary links; guidelines) Active alerts (No BP for > 5 min; Hypothermia, per SCIP; Risk of Awareness) Role of Time Specific Rules Multiple Parameters Personalized alerts and notifications Clinical Decision Support System (DSS)
36 Customizable and Dynamic DSS Content
37 Customizable and Dynamic DSS Content
38 Customizable and Dynamic DSS Content
39 Customizable and Dynamic DSS Content
40 DSS - Blackberry Version Access to DSS Directly from Blackberry Browser From within DSS alerts Either method features auto logon Vitals Medical History Case Summary Medications (Inpatient & Outpatient) Alerts (can be acknowledged from BB) Allows direct calls to the OR
41 DSS Control Desk
42 DSS Control Desk
43 A Carnegie Avenue Control Desk
44 Allows adverse physiologic developments to be addressed before they become crises Allows staff assignment according to needs Control Desk
45 Clinical Dashboard
46 Operational Clinical Dashboard
47 Operational Clinical Dashboard
48 Clinical Dashboard
49 Operational Dashboard
50 Operational Dashboard
51 Operational Dashboard
52 Operational Dashboard
53 Operational Dashboard
54 Operational Dashboard
55 Operational Dashboard
56 Operational Dashboard
57 Operational Dashboard
58 13 staff 7 staff 3 staff Operational Dashboard
59 8 staff (instead of 13) 4 staff (instead of 7) 2 staff (instead of 3) 9 staff freed up DESK PAIN TEE PACU PAT Operational Dashboard
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